Peer Support (Adult/Family/Youth) Fidelity Checklist Agency: Service: _______ Date: Reviewer: ________________________________ Enter a 1-5 for the rating for the percentage of chart/interview based on observation or found documented during the visit about Peer Delivered Services (PDS). 1. PEER DELIVERED SERVICES AVAILABILITY Rating Comments Observations or chart review 1 -5 1 Is there a note that the PWS, PSS, FSS or YSS 2 explained PDS 1 2 3 4 5 Did the client have access to PWS, 1 2 3 4 5 PSS, FSS or YSS at the time of each appointment? Is PDS considered/included during 1 2 3 4 5 intake and/or referral? Did the client have access to PDS to 1 2 3 4 5 prepare for appointments? Is there documentation the client had 1 2 3 4 5 access to PDS after appointments? Is PDS considered/included as part of 1 2 3 4 5 the treatment plan? Is PDS available outside of the building (at the client’s home, in the 1 2 3 4 5 community, by telephone? 2. PEER DELIVERED SERVICES STAFFING Rating Comment Observations or chart review 1-5 1 Is the PWS/PSS/FSS/YSS 1 2 3 4 5 integrated in team/staffing meetings? Is the PWS/PSS/FSS/YSS on the 1 2 3 4 5 OEI/THW registry and registered as a Medicaid/CCO provider? 1 2 3 4 5 Is the PWS/PSS/FSS/YSS operating within their scope of practice? Does the PWS/PSS/FSS/YSS 1 2 3 4 5 receive weekly consultation from a 1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100% 2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 1 of 4
Peer Support (Adult/Family/Youth) Fidelity Checklist clinician and a PWS/PSS/FSS/YSS in the same field of practice? Are PWS/PSS/FSS/YSS supervised by a peer supervisor who has lived 1 2 3 4 5 and professional experience in the same field of practice Are PWS/PSS/FSS/YSS regularly 1 2 3 4 5 considered/included in the development of the services and treatment plans? Do PWS/PSS/FSS/YSS receive 1 2 3 4 5 regular continued education opportunities? Are PWS/PSS/FSS/YSS encouraged to join and participate 1 2 3 4 5 in regional, state or national meetings of their discipline? 3. PEER DELIVERED SERVICES DELIVERY Rating Comment Observations or chart review 1-5 1 Is the PDS documentation 1 2 3 4 5 developed, reviewed and approved by the client? Is the client able to choose a 1 2 3 4 5 PWS/PSS/FSS/YSS who reflects their goals and culture? Does the PWS/PSS/FSS/YSS advocate according to the client’s 1 2 3 4 5 wishes and goals on the treatment team, in services systems, and in the community? Does the PWS/PSS/FSS/YSS support a network of “warm -hand off” in referrals to agency partners, 1 2 3 4 5 community members or other PWS/PSS/FSS/YSS? Is there documentation that that the PWS/PSS/FSS/YSS has provided the client sufficient information in 1 2 3 4 5 order to make decisions related to treatment choices, resources, and do 1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100% 2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 2 of 4
Peer Support (Adult/Family/Youth) Fidelity Checklist they exercise personal rights and responsibilities? Is there documentation that that the PWS/PSS/FSS/YSS has provided 1 2 3 4 5 the client sufficient information and support to exercise their personal rights and responsibilities? Is there documentation that the client is more informed and feels 1 2 3 4 5 confident to advocate for self or family members as a result of having PDS? Is there documentation that the 1 2 3 4 5 client is more hopeful and supported as a result of receiving PDS? 4. ORGANIZATIONAL SUPPORT FOR PEER DELIVERED SERVICES Rating Comment Observations or chart review 1-5 1 Has the organization developed a 1 2 3 4 5 communication and support plan to bring PDS to patients/clients? Has the organization developed information to be shared as part of intake process that the 1 2 3 4 5 PWS/PSS/FSS/YSS can use with patient/client to describe the peer support role, its purpose and potential benefits? Do all supervisors encourage their staff to include the 1 2 3 4 5 description of PDS and the use of PWS/PSS/FSS/YSS as part of the intake process? Do all supervisors encourage their staff to include the 1 2 3 4 5 description of PDS and the use of PWS/PSS/FSS/YSS as part of the treatment or services process? 1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100% 2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 3 of 4
Peer Support (Adult/Family/Youth) Fidelity Checklist Does the organization have orientation and training for 1 2 3 4 5 PWS/PSS/FSS/YSS that is specific to their role within the organization, to educate agency staff, contractors and volunteers? Does the organization have orientation and training for all 1 2 3 4 5 staff within the organization, to educate agency staff, contractors and volunteers about the role of each type of PDS? Does the organization include the PWS/PSS/FSS/YSS 1 2 3 4 5 supervisor/manager in the leadership/management team? 6. Additional Recommendations: ___________________________________ __________________________________ Name and Signature (Reviewer) Name and Signature (Agency) 1 Rating is based on percentage of fidelity occurrence: 1 = 0-20%, 2 = 21-40%, 3 = 41-60%. 4 = 61-80%. 5 = 81-100% 2 Peer Wellness Specialist (PWS), Peer Support Specialists (PSS), Family Support Specialist (FSS) or Youth Support Specialist (YSS). See AOR 410-180 for definition and certification requirements. Peer Delivered Services Fidelity Checklist July 2018 frances.s.purdy@state.or.us 4 of 4
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